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Carvedilol bests propranolol in patients with cirrhosis

Research published in The American Journal of Gastroenterology suggests carvedilol, not propranolol, may lower the portal pressure gradient in patients with MELD scores greater than or equal to 15.

“The primary aim of this study was to evaluate the efficacy of carvedilol for reducing [hepatic venous pressure gradient (HVPG)] in patients with cirrhosis and severe portal hypertension as compared with that of propranolol,” Sang G. Kim, MD, PhD, of the division of gastroenterology and hepatology at Soonchunhyang University College of Medicine in Korea, and colleagues wrote. “We also evaluated drug compliance and safety, and identified predicting factors associated with the hemodynamic response among these patients.”

In this randomized, multicenter open-label study, researchers looked at 110 patients aged between 20 and 70 years with cirrhosis who had a baseline HVPG greater than 12 mmHg, an endoscopy-proven varix grade 2 or 3 within the past 3 months, a Child-Pugh score less than 12 and had not took vasoactive drugs 1 month prior to the study’s start. Researchers assigned half of the patients  carvedilol and the other half propranolol.

According to researchers, patients assigned carvedilol received 6.25 mg per day for 6 weeks and patients assigned propranolol received 20 mg twice a day, also for 6 weeks. The carvedilol dose increased to 12.5 mg; propranolol was titrated weekly up to 320 mg until heart rate decreased by 25% from baseline or up to 55 beats per minute if tolerable by the patient and systolic blood pressure was greater than 90 mm Hg. Researchers calculated patients’ HVPG again after the 6 week period.

Researchers wrote the decrease in mean HVPG was well-defined in the carvedilol (−3.5 ± 4.8 mm Hg, P < .001) and propranolol groups (−2 ± 5.5 mm Hg, P = .021); however, it was not statistically different between the two groups (P = .163). Further, the overall response rate did not quite reach acceptable levels of statistical significance in intention to treat (P = .08) and per-protocol analyses (P = .137), although response rate to carvedilol (49.1%) was slightly higher than that of propranolol (30.9%).

Kim and colleagues observed some adverse events — ascites growth, esophageal variceal bleeding, generalized edema —in both groups. Though these occurred slightly more in the carvedilol group, researchers could not find a correlation between the events and the medication.

“Overall, carvedilol offered no clear advantage over propranolol but it might be more effective in more advanced cirrhotic patients with a MELD score [greater than or equal to] 15,” Kim and researchers wrote. “This potential benefit might come with a cost of increased risk of side-effects.” – by Janel Miller

Disclosure: The researchers report no relevant financial disclosures.